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Professional Practice Guidelines and Consensus Documents from the ISHLT
The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients
David Baran, Tiffany Buda, Adam Cochrane, Maria Crespo Leiro, Anne Dipchand, Brian Feingold, Kathleen Grady, Edward Horn, Maryl Johnson, Donna Mancini, Sean Pinney, Heather Ross, Kari Wujcik, Andreas Zuckermann(Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7a, Table 7b, Table 8, Table 9, Table 10, Table 11, Table 12, Table 13, Table 14)Reproductive health after thoracic transplantation: An ISHLT expert consensus statement
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.Donor heart selection: Evidence-based guidelines for providers
The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery
Pulmonary hypertension (PH) is a risk factor for morbidity and mortality in patients undergoing surgery and anesthesia. This document represents the first international consensus statement for the perioperative management of patients with pulmonary hypertension and right heart failure. It includes recommendations for managing patients with PH being considered for surgery, including preoperative risk assessment, planning, intra- and postoperative monitoring and management strategies that can improve outcomes in this vulnerable population.Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search.ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part I: Epidemiology, assessment of extrapulmonary conditions, candidate evaluation, selection criteria, and pathology statements
Patients with connective tissue disease (CTD) and advanced lung disease are often considered suboptimal candidates for lung transplantation (LTx) due to their underlying medical complexity and potential surgical risk. There is substantial variability across LTx centers regarding the evaluation and listing of these patients. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization aims to clarify definitions of each disease state included under the term CTD, to describe the extrapulmonary manifestations of each disease requiring consideration before transplantation, and to outline the absolute contraindications to transplantation allowing risk stratification during the evaluation and selection of candidates for LTx.Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates.ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association
Heart failure (HF) is a significant cause of mortality in children and therefore there is interest in understanding the optimal way to support these children with Ventricular Assist Devices (VAD) to improve outcomes. VAD therapy is now regarded as an important treatment option in pediatric HF. The 2019 International Society for Heart and Lung Transplantation (ISHLT) registry report shows that there is an increasing trend towards using VADs as a bridge to transplant (BTT) with currently over one-third of patients transplanted being bridged with a VAD.International Society for Heart and Lung Transplantation consensus statement for the standardization of bronchoalveolar lavage in lung transplantation
Bronchoalveolar lavage (BAL) is a key clinical and research tool in lung transplantation (LTx). However, BAL collection and processing are not standardized across LTx centers. This International Society for Heart and Lung Transplantation–supported consensus document on BAL standardization aims to clarify definitions and propose common approaches to improve clinical and research practice standards. The following 9 areas are covered: (1) bronchoscopy procedure and BAL collection, (2) sample handling, (3) sample processing for microbiology, (4) cytology, (5) research, (6) microbiome, (7) sample inventory/tracking, (8) donor bronchoscopy, and (9) pediatric considerations.Report from the 2018 consensus conference on immunomodulating agents in thoracic transplantation: Access, formulations, generics, therapeutic drug monitoring, and special populations
In 2009, the International Society for Heart and Lung Transplantation recognized the importance and challenges surrounding generic drug immunosuppression. As experience with generics has expanded and comfort has increased, substantial issues have arisen since that time with other aspects of immunomodulation that have not been addressed, such as access to medicines, alternative immunosuppression formulations, additional generics, implications on therapeutic drug monitoring, and implications for special populations such as pediatrics and older adults.Donor heart and lung procurement: A consensus statement
Heart and lung procurements are multiphased processes often accompanied by an array of complex logistics. Approaches to donor evaluation and management, organ procurement, and organ preservation vary among individual procurement teams. Because early graft failure remains a major cause of mortality in contemporary thoracic organ transplant recipients, we sought to establish some standardization in the procurement process. This paper, in this vein, represents an international consensus statement on donor heart and lung procurement and is designed to serve as a guide for physicians, surgeons, and other providers who manage donors to best optimize the clinical status for the procurement of both heart and lungs for transplantation.Utilization of hepatitis C virus–infected organ donors in cardiothoracic transplantation: An ISHLT expert consensus statement
The advent of therapies for successful treatment of hepatitis C virus has allowed the heart and lung transplant community to re-explore the use of hepatitis C virus–positive donors for organ transplantation, with a benefit for many terminally ill patients. The consensus statements provided herein represent the current state of knowledge and expertise in this area, which we expect will continue to rapidly evolve over the next few years.ISHLT consensus statement on donor organ acceptability and management in pediatric heart transplantation
The number of potential pediatric heart transplant recipients continues to exceed the number of donors, and consequently the waitlist mortality remains significant. Despite this, around 40% of all donated organs are not used and are discarded. This document (62 authors from 53 institutions in 17 countries) evaluates factors responsible for discarding donor hearts and makes recommendations regarding donor heart acceptance. The aim of this statement is to ensure that no usable donor heart is discarded, waitlist mortality is reduced, and post-transplant survival is not adversely impacted.American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support
Mechanical circulatory support (MCS) evolved from an engineering dream to clinical reality during the 1980s when increasing numbers of patients were dying on heart transplant wait lists. Following the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure Trial,1 the US Food and Drug Administration (FDA) approved a pulsatile implantable left ventricular assist device (LVAD) for long-term implantation in 2002. When the FDA approved the first US continuous flow (CF) LVAD in 2008, the landscape had changed dramatically.HFSA/SAEM/ISHLT clinical expert consensus document on the emergency management of patients with ventricular assist devices
Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care.2019 updated consensus statement on the diagnosis and treatment of pediatric pulmonary hypertension: The European Pediatric Pulmonary Vascular Disease Network (EPPVDN), endorsed by AEPC, ESPR and ISHLT
The European Pediatric Pulmonary Vascular Disease Network is a registered, non-profit organization that strives to define and develop effective, innovative diagnostic methods and treatment options in all forms of pediatric pulmonary hypertensive vascular disease, including pulmonary hypertension (PH) associated with bronchopulmonary dysplasia, PH associated with congenital heart disease (CHD), persistent PH of the newborn, and related cardiac dysfunction. The executive writing group members conducted searches of the PubMed/MEDLINE bibliographic database (1990–2018) and held face-to-face and web-based meetings.Chronic lung allograft dysfunction: Definition and update of restrictive allograft syndrome―A consensus report from the Pulmonary Council of the ISHLT
Since the inception of lung transplantation (LTx), serial pulmonary function testing (PFT) has been the primary method of quantifying the physiologic performance of the allograft. The spirometric indices have since been the standard benchmark to detect the emergence of chronic allograft dysfunction (CLAD). Historic descriptions of physiologic and histologic findings in the first heart‒lung transplant (HLTx) recipients formed the basis for our initial understanding of chronic dysfunction of the pulmonary allograft.Chronic lung allograft dysfunction: Definition, diagnostic criteria, and approaches to treatment―A consensus report from the Pulmonary Council of the ISHLT
The outcomes of transplantation vary widely by organ. Lung transplantation (LTx) has rather poor long-term outcome, with a current median post-transplant survival of 6.0 years.1,2 Survival after organ transplantation is limited by both graft-related and non‒graft-related factors. Allograft failure remains the leading cause of morbidity and mortality across all organ groups and is the major cause of death, accounting for >40% of deaths beyond the first year post-LTx.1,2The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support
The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients’ receipt of and response to interventions for any problems identified.ISHLT Consensus Statement on adult and pediatric airway complications after lung transplantation: Definitions, grading system, and therapeutics
Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system.The management of antibodies in heart transplantation: An ISHLT consensus document
Despite the successes from refined peri-operative management techniques and immunosuppressive therapies, antibodies remain a serious cause of morbidity and mortality for patients both before and after heart transplantation. Patients awaiting transplant who possess antibodies against human leukocyte antigen are disadvantaged by having to wait longer to receive an organ from a suitably matched donor. The number of pre-sensitized patients has been increasing, a trend that is likely due to the increased use of mechanical circulatory support devices.Report of the ISHLT Working Group on Primary Lung Graft Dysfunction, part I: Definition and grading—A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation
Primary graft dysfunction (PGD) refers to the syndrome of acute lung injury early after lung transplantation (LTx).1 In 2005, based on the need for a reliable and valid definition with clear taxonomy, the first International Society for Heart and Lung Transplantation (ISHLT) Working Group on PGD proposed a consensus-based standardized definition and grading system.1 This definition has since been used to characterize PGD clinically by diffuse alveolar infiltrates on chest X-ray imaging, with the degree of associated hypoxemia determining its severity (Table 1).An ISHLT consensus document for prevention and management strategies for mechanical circulatory support infection
Heart failure (HF) remains a major cause of morbidity and mortality. Heart transplantation (HT) is a life-saving procedure for patients with advanced heart failure, but availability is limited by donor organ shortage.1 Durable mechanical circulatory support (MCS) is a major advance in HF management and can provide hemodynamic support until myocardial recovery or HT, or as permanent therapy (destination therapy, DT) for those ineligible for HT.2 MCS has continued to enhance patient survival and quality of life through continued improvements in device design and durability.Antibody-mediated rejection of the lung: A consensus report of the International Society for Heart and Lung Transplantation
Antibody-mediated rejection (AMR) is a recognized cause of allograft dysfunction in lung transplant recipients. Unlike AMR in other solid-organ transplant recipients, there are no standardized diagnostic criteria or an agreed-upon definition. Hence, a working group was created by the International Society for Heart and Lung Transplantation with the aim of determining criteria for pulmonary AMR and establishing a definition. Diagnostic criteria and a working consensus definition were established.
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